Universal care is possible, but not without sacrifices

I am an emergency physician practicing since 1990, and it was my pleasure during a recent vacation home to Kaneohe to read Princeton University economist Paul Krugman's column regarding the solutions to our nation's broken health care system offered by a universal health care plan (Star-Bulletin, Aug. 12). Our emergency departments are the ideal places to witness the failures of our current system and I see them every day; from mundane to tragic. I agree with Krugman that some form of universal health care is our best option, and would add that our current system is flatly unethical. He correctly pointed out the daunting hurdles to change of politics, fear and apathy. But he missed the biggest hurdle - American culture.

It is true that other developed countries are doing well by most measures with their universal health systems. They are more ethical, less expensive and equitable. But they exist in cultures willing to decide what medical care is not going to be provided by the system. They have made decisions about what care will not be provided. In these countries you don't necessarily get a kidney transplant or even dialysis at age 85, a feeding tube if you can't ask for it yourself or an MRI because you insist on one for your strained back. What you do get you might have to wait for and whatever tort relief for malpractice isn't a lottery for wealth.

Krugman references a new system that would be affordable, accessible and comprehensive. No solution, whether from an economist or a politician unwilling or unable to define "comprehensive," amounts to more than wishful thinking at best and pandering at worst. Should we spend half of our individual health care expenditures in the last few months of our lives in the ICU on ventilators? Should liver transplants be available to all, regardless of age and of ongoing alcohol abuse? Should we be tube-fed to prolong life regardless of the quality of life? Should a very effective but inexpensive treatment be supplanted by an arguably slightly more effective treatment that costs a great deal more?

The answers to these questions are very different in other countries. The problem with accessible, affordable and undefined "comprehensive" health care is that it is not sustainable economically. We have to set about defining what we mean by "health care" itself. If we want it all, then we will have to pay, pay more and still more.

Despite the laudable successes of Medicare, it has its own ticking demographic time bomb. There are fewer and fewer young workers paying the taxes to support more and more of us over age 65. Additional costs in sad need of redress include tort reform and unconscionable profit by some insurance companies, healthcare executives, medical device companies and the pharmaceutical industry. Many of these are in bed with their own governmental oversight agencies. These problems can be more effectively addressed with a universal system to balance the big business aspects of our current system and can reduce costs. But most importantly, the current political and economic reality is that comprehensive health care is a privilege, not a right. Few of our leaders and sadly fewer of our elected leaders will admit it, and we are paying too much for it.

We live in the real world, where dreams don't just come true. We have to apply the lens of reality and be willing to work hard to make things the best they can be, accept that we cannot have it all. Resources used in one place mean less for something else. We must stop borrowing from our own children's futures. In an ethical society, health care is a right. But we must be willing to roll up our sleeves and define just what that health care should be. It cannot be everything for everyone all of the time. Tough decisions need to be made with great care.

My dream is that someday a viable high-ranking political leader in the midst of a campaign will answer straight up just what is not going to be covered in their universal health care plan. My fantasy is that such a leader could actually get elected. Until then, expect nothing more than fancy talk, wasted flailing and wailing about out-of-control costs, and a lousy system that we have foisted upon ourselves.

Our leaders can do better. We can do better.

Kirk Lufkin, M.D., is the medical director of Portage Health in Hancock, Mich. He graduated from the University of Hawaii medical school in 1986.